Multimodal Biomarkers That Predict the Presence of Gleason Pattern 4: Potential Impact for Active Surveillance

PURPOSE

Latent grade group ≥2 prostate cancer can impact the performance of active surveillance protocols. To date, molecular biomarkers for active surveillance have relied solely on RNA or protein. We trained and independently validated multimodal (mRNA abundance, DNA methylation, and/or DNA copy number) biomarkers that more accurately separate grade group 1 from grade group ≥2 cancers.

MATERIALS AND METHODS

Low- and intermediate-risk prostate cancer patients were assigned to training (n=333) and validation (n=202) cohorts. We profiled the abundance of 342 mRNAs, 100 DNA copy number alteration loci, and 14 hypermethylation sites at 2 locations per tumor. Using the training cohort with cross-validation, we evaluated methods for training classifiers of pathological grade group ≥2 in centrally reviewed radical prostatectomies. We trained 2 distinct classifiers, PRONTO-e and PRONTO-m, and validated them in an independent radical prostatectomy cohort.

RESULTS

PRONTO-e comprises 353 mRNA and copy number alteration features. PRONTO-m includes 94 clinical, mRNAs, copy number alterations, and methylation features at 14 and 12 loci, respectively. In independent validation, PRONTO-e and PRONTO-m predicted grade group ≥2 with respective true-positive rates of 0.81 and 0.76, and false-positive rates of 0.43 and 0.26. Both classifiers were resistant to sampling error and identified more upgrading cases than a well-validated presurgical risk calculator, CAPRA (Cancer of the Prostate Risk Assessment; P < .001).

CONCLUSIONS

Two grade group classifiers with superior accuracy were developed by incorporating RNA and DNA features and validated in an independent cohort. Upon further validation in biopsy samples, classifiers with these performance characteristics could refine selection of men for active surveillance, extending their treatment-free survival and intervals between surveillance.

715 Implementation of Enhanced Recovery After Surgery (ERAS) in Total Laryngectomies

Aim

The Enhanced Recovery After Surgery (ERAS) protocol for total laryngectomies was first implemented in our tertiary head and neck centre from November 2019. It includes pre-operative carbohydrate loading and an early swallow test which facilitates recommencement of oral intake to improve outcomes. Protocol adherence rate and patient outcomes were measured to determine the effectiveness and benefits of ERAS in laryngectomy patients.

Method

22 total laryngectomy patients from November 2019 to September 2021 were enrolled onto the ERAS protocol, 18 primary and 3 salvage cases. An analysis of the respective patient cohorts was performed to determine adherence to the ERAS protocol and outcomes such as complications and length of inpatient stay were measured.

Results

19 patients (86%) received pre-operative carbohydrate loading successfully, while 3 patients were contraindicated due to background of diabetes. Early swallow test was performed in 59% of patients. Potential reasons for delay were stoma dehiscence or clinical suspicion of neo-pharyngeal leak. 59% of primary cases were deemed medically fit for discharge within the target timeframe of 12–14 days whereas no target was set for salvage cases due to expected poor healing. Main complication in primary cases was neo-pharyngeal leak followed by stoma dehiscence with 28% and 11% respectively.

Conclusion

Limitations of our study include small sample size due to the COVID-19 pandemic. Despite its infancy, the ERAS protocol has achieved good outcomes in early recommencement of oral intake post-laryngectomy and encouraging early safe discharge from hospital. Future plans include establishment of Prehab Clinic and application of ERAS to neck dissection patients.

Enhanced monocyte recruitment and delayed alternative macrophage polarization accompanies impaired repair following myocardial infarction in C57BL/6 compared to BALB/c mice

Activation of the innate immune response following myocardial infarction (MI) is essential for infarct repair. Preclinical models of MI commonly use C57BL/6 mice, which have a type 1‐dominant immune response, whereas other mouse strains such as BALB/c mice have a type 2‐dominant immune response. We compared C57BL/6 and BALB/c mice to investigate whether predisposition towards a proinflammatory phenotype influences the dynamics of the innate immune response to MI and associated infarct healing and the risk of cardiac rupture. MI was induced by permanent coronary artery ligation in 12–15‐week‐old male wild‐type BALB/c and C57BL/6 mice. Prior to MI, C57BL/6 mice had a lower proportion of CD206⁺ anti‐inflammatory macrophages in the heart and an expanded blood pool of proinflammatory Ly6C^high monocytes in comparison to BALB/c mice. The systemic inflammatory response in C57BL/6 mice following MI was more pronounced, with greater peripheral blood Ly6C^high monocytosis, splenic Ly6C^high monocyte mobilization and myeloid cell infiltration of pericardial adipose tissue. This led to an increased and prolonged macrophage accumulation, as well as delayed transition towards anti‐inflammatory macrophage polarization in the infarct zone and surrounding tissues of C57BL/6 mice. These findings accompanied a higher rate of mortality due to cardiac rupture in C57BL/6 mice compared with BALB/c mice. We conclude that lower post‐MI survival of C57BL/6 mice over BALB/c mice is mediated in part by a more pronounced and prolonged inflammatory response. Outcomes in BALB/c mice highlight the therapeutic potential of modulating resolution of the innate immune response following MI for the benefit of successful infarct healing.

Junior doctors' perspectives on transfusion education in Australia

BACKGROUND

Early postgraduate training is a critical period to develop skills and to influence future clinical practice. Little is known about Australian junior doctors' existing transfusion knowledge and its application in patient care. This study explored their transfusion practice education preferences, developed tools to assist their practice and assessed the usefulness of these tools.

METHODS

A design-based study was conducted in two phases from April 2016 to March 2017. Phase 1 involved focus group sessions in six hospitals. Transcripts of audio recordings were analysed using thematic analysis. Findings were considered when developing transfusion practice support tools. Phase 2 surveyed junior doctors' response to the tools provided during orientation in five hospitals. Participation was voluntary.

RESULTS

Fifty-two junior doctors participated in the focus groups. Their priority was to be able to practice safely, appropriately and confidently. Preferred format for transfusion learning included expert-led face-to-face education; printed tools, for example lanyard cards; and for one app that covers essential aspects of transfusion practice. Adverse events management and practical transfusion prescribing were topics of most importance. Thirty-nine survey respondents found the transfusion practice support tools useful and recommended their use to complement practice.

CONCLUSION

There is a need for improved education to ensure best transfusion practice and patient outcomes. Australian junior doctors want immediate, practical, reliable transfusion information from credible sources to support them in practicing safely and confidently. Their educational needs are driven by real-time patient management. Promotion of the available resources and tools provided by the blood sector is important.

Post-mortem prediction of primal and selected retail cut weights of New Zealand lamb from carcass and animal characteristics

Post-mortem measurements (cold weight, grade and external carcass linear dimensions) as well as live animal data (age, breed, sex) were used to predict ovine primal and retail cut weights for 792 lamb carcases. Significant levels of variance could be explained using these predictors. The predictive power of those measurements on primal and retail cut weights was studied by using the results from principal component analysis and the absolute value of the t-statistics of the linear regression model. High prediction accuracy for primal cut weight was achieved (adjusted R(2) up to 0.95), as well as moderate accuracy for key retail cut weight: tenderloins (adj-R(2)=0.60), loin (adj-R(2)=0.62), French rack (adj-R(2)=0.76) and rump (adj-R(2)=0.75). The carcass cold weight had the best predictive power, with the accuracy increasing by around 10% after including the next three most significant variables.

Endoscopic retrograde cholangiopancreatography in the treatment of intraoperatively demonstrated choledocholithiasis

INTRODUCTION

The aim of this study was to determine the efficacy and complications of postoperative endoscopic retrograde cholangiopancreatography (ERCP) in confirming and treating choledocholithiasis found at intraoperative cholangiography during laparoscopic cholecystectomy.

METHODS

Patients who had undergone ERCP following a cholecystectomy between 2008 and 2011 with an indication of intraoperative cholangiography findings consistent with choledocholithiasis were identified from a prospectively collected database of a single endoscopist. Deep biliary access rate, confirmation of choledocholithiasis, clearance rate of bile duct stones, delay between cholecystectomy and postoperative ERCP, and the complication rates following the procedure were analysed.

RESULTS

The median age of the 41 patients (16 male, 25 female) was 42 years (range: 18–82 years). Sixteen surgeons performed the operations with a median delay of 6 days (range: 1–103 days) between cholecystectomy and postoperative ERCP. Common bile duct access was achieved in 100% of the patients, with ERCP taking a median time of 16 minutes (range: 6–40 minutes). Initial ERCP confirmed the presence of a stone in 30 patients (73%) and successful stone removal occurred in 28 of these 30 patients (93%) during the first ERCP and in the remaining 2 on a subsequent ERCP. Following ERCP, two patients (4.9%) experienced extended hospital stays for four and eight days owing to complications, including one patient (2.4%) with mild acute pancreatitis.

CONCLUSIONS

This study demonstrates that postoperative ERCP is highly effective in both confirming and treating choledocholithiasis. However, there is a significant risk of short-term complications that must be taken into consideration when deciding management.

Detection of clinically relevant pain relief in cats with degenerative joint disease associated pain

Background

Detection of clinically relevant pain relief in cats with degenerative joint disease (DJD) is complicated by a lack of validated outcome measures and a placebo effect.

Hypothesis/Objectives

To evaluate a novel approach for detection of pain relief in cats with DJD.

Animals

Fifty‐eight client‐owned cats.

Methods

Prospective, double‐masked, placebo‐controlled, stratified, randomized, clinical study. Enrolled cats were 6–21 years of age, with owner‐observed mobility impairment, evidence of pain in at least 2 joints during orthopedic examination, and overlapping radiographic evidence of DJD, and underwent a 2‐week baseline period, 3‐week treatment period with placebo or meloxicam, and 3‐week masked washout period. Outcome measures were evaluated at days 0, 15, 36, and 57.

Results

Both groups significantly improved after the treatment period (day 36) on client‐specific outcome measures (CSOM) and feline musculoskeletal pain index (FMPI) (P < .0001 for both); there was no difference between the groups on CSOM or FMPI score improvement. After the masked washout period, more cats that received meloxicam during the treatment period had a clinically relevant decrease in CSOM score (P = .048) and FMPI score (P = .021) than cats that received placebo.

Conclusions and Clinical Importance

Using both a client‐specific and a general clinical metrology instrument, owners of cats with DJD were able to detect evident recurrence of clinical signs after withdrawal of active medication than after withdrawal of placebo, and that this study design might be a novel and useful way to circumvent the placebo effect and detect the efficacy of pain‐relieving medications.

Phase II trial of docetaxel, cisplatin and 5FU chemotherapy in locally advanced and metastatic penis cancer (CRUK/09/001)

BACKGROUND

Penis cancer is rare and clinical trial evidence on which to base treatment decisions is limited. Case reports suggest that the combination of docetaxel, cisplatin and 5-flurouracil (TPF) is highly active in this disease.

METHODS

Twenty-nine patients with locally advanced or metastatic squamous carcinoma of the penis were recruited into a single-arm phase II trial from nine UK centres. Up to three cycles of chemotherapy were received (docetaxel 75 mg m(-2) day 1, cisplatin 60 mg m(-2) day 1, 5-flurouracil 750 mg m(-2) per day days 1-5, repeated every 3 weeks). Primary outcome was objective response (assessed by RECIST). Fourteen or more responses in 26 evaluable patients were required to confirm a response rate of 60% or higher (Fleming-A'Hern design), warranting further evaluation. Secondary endpoints included toxicity and survival.

RESULTS

10/26 evaluable patients (38.5%, 95% CI: 20.2-59.4) achieved an objective response. Two patients with locally advanced disease achieved radiological complete remission. 65.5% of patients experienced at least one grade 3/4 adverse event.

CONCLUSION

Docetaxel, cisplatin and 5FU did not reach the pre-determined threshold for further research and caused significant toxicity. Our results do not support the routine use of TPF. The observed complete responses support further investigation of combination chemotherapy in the neoadjuvant setting.

A randomised controlled trial of abdominal versus laparoscopic sacrocolpopexy for the treatment of post-hysterectomy vaginal vault prolapse: LAS study

INTRODUCTION AND HYPOTHESIS

This prospective multi-centre true two-sided equivalence trial was designed to test the clinical equivalence of open (ASCP) and laparoscopic (LSCP) sacrocolpopexy using objective and subjective outcomes

METHODS

The study was carried out in three urogynaecology units in England, UK and the patient population consisted of women referred with symptomatic and bothersome post-hysterectomy vaginal vault prolapse at least 1 cm above or beyond the hymeneal remnants. The interventions were either abdominal or laparoscopic sacrocolpopexy following randomisation to one of the types of surgery.

RESULTS

For the primary outcome (point C on the POP-Q) the results at 1 year were -6.63 cm for the open ASCP and -6.67 cm for the LSCP respectively. Subjective outcomes at 1 year showed that 90% of the ASCP group and 80% of the LSCP group were "much better". There were improvements with regard to blood loss, haemoglobin and shorter length of stay in the LSCP group compared with the ASCP group.

CONCLUSION

This fully powered randomised controlled trial comparing open and laparoscopic sacrocolpopexy has shown clinical equivalence.

Feedback on doctors' performance from parents and carers of children: a national pilot study

OBJECTIVES

To evaluate the reliability and validity of a children's carers' feedback tool, to explore the feasibility of delivering this nationally and to determine acceptability to doctors of this assessment.

PARTICIPANTS

122 UK paediatricians on the specialist register undertaking outpatient consultations.

DESIGN

Participants were each sent 50 forms for distribution to carers. Mean scores for each question, and for the overall pilot cohort were returned to participants with verbatim free text comments. Participating paediatricians' views were sought before and after receiving feedback.

RESULTS

122 doctors returned 4415 forms (mean 36 per doctor). All doctors scored highly with scores across all returned forms having a median of 4.58 (IQ range 0.17) where the maximum score was 5. Differences were observed between scores from female compared to male carers (p<0.05), from consultations rated by carer and child compared to carer alone (p<0.05) and from carers who had previously met the doctor compared to those in their first consultation (p<0.001). 'White' doctors received higher ratings than 'non-white' doctors (p<0.05) and white patients rated both white doctors and non-white doctors more highly than non-white patients (p<0.01). A minimum of 25 consultations rated by children's carers are needed for acceptable reliability. 93.9% of participants would be happy to be assessed in this way for the purposes of revalidation.

CONCLUSIONS

National delivery of a valid and reliable method of carer feedback is feasible. The scores received and acceptability in these self-selected doctors was high. Confounding variables may influence feedback, so guidance on interpretation may be needed.

Comparative analysis of genome-wide association studies signals for lipids, diabetes, and coronary heart disease: Cardiovascular Biomarker Genetics Collaboration

Aims

To evaluate the associations of emergent genome-wide-association study-derived coronary heart disease (CHD)-associated single nucleotide polymorphisms (SNPs) with established and emerging risk factors, and the association of genome-wide-association study-derived lipid-associated SNPs with other risk factors and CHD events.

Methods and results

Using two case–control studies, three cross-sectional, and seven prospective studies with up to 25 000 individuals and 5794 CHD events we evaluated associations of 34 genome-wide-association study-identified SNPs with CHD risk and 16 CHD-associated risk factors or biomarkers. The Ch9p21 SNPs rs1333049 (OR 1.17; 95% confidence limits 1.11–1.24) and rs10757274 (OR 1.17; 1.09–1.26), MIA3 rs17465637 (OR 1.10; 1.04–1.15), Ch2q36 rs2943634 (OR 1.08; 1.03–1.14), APC rs383830 (OR 1.10; 1.02, 1.18), MTHFD1L rs6922269 (OR 1.10; 1.03, 1.16), CXCL12 rs501120 (OR 1.12; 1.04, 1.20), and SMAD3 rs17228212 (OR 1.11; 1.05, 1.17) were all associated with CHD risk, but not with the CHD biomarkers and risk factors measured. Among the 20 blood lipid-related SNPs, LPL rs17411031 was associated with a lower risk of CHD (OR 0.91; 0.84–0.97), an increase in Apolipoprotein AI and HDL-cholesterol, and reduced triglycerides. SORT1 rs599839 was associated with CHD risk (OR 1.20; 1.15–1.26) as well as total- and LDL-cholesterol, and apolipoprotein B. ANGPTL3 rs12042319 was associated with CHD risk (OR 1.11; 1.03, 1.19), total- and LDL-cholesterol, triglycerides, and interleukin-6.

Conclusion

Several SNPs predicting CHD events appear to involve pathways not currently indexed by the established or emerging risk factors; others involved changes in blood lipids including triglycerides or HDL-cholesterol as well as LDL-cholesterol. The overlapping association of SNPs with multiple risk factors and biomarkers supports the existence of shared points of regulation for these phenotypes.